1. Clinical Case Illustrating Chronic Care Management Driven Success: Home is Where the Heart Is Kyley Ogard, MSN GNP-C ANP-C May 18, 2016

2. Disclosures Employee of Kindred Health Care

3. Objectives Use the information presented to improve their care planning practices.

4. Chronic Care Management: What is it? CMS added a new CPT 99490 effective January 1, 2015 with a national allowed amount of $42.60 to cover your provided chronic care management services to those eligible.

5. CCM: What is it? CMS requires 20 minutes per calendar month of documented clinical staff time directed by a physician or other qualified healthcare professional

6. CCM: What is it? Patient must have multiple (TWO or more) chronic conditions expected to last at least 12 months, or until death of patient Chronic conditions place patient at significant risk of death, acute exacerbation/decompensation, or functional decline A comprehensive plan must be established, implemented, revised, and monitored.

7. CMS Elements of Service 24/7 access to care Continuity of care with designated team member Creation of comprehensive patient-centered care plan based on assessments of physical, mental, cognitive, psychosocial, functional, and environmental assessments

8. CMS Elements of Service Management of chronic conditions Management of care transitions Coordination with home and community-based service providers Enhanced opportunities for beneficiary and caregivers to communicate with providers regarding care

9. Additional CMS Requirements Documented consent 20% beneficiary co-payment applies Only one Part B provider can be paid for CCM in one calendar month Use a certified EHR Cannot bill CPT codes for CPO, TCM, hospice, and certain ESRD codes same month as CCM CPT

10. Case Study: GG Feb 2015: consent obtained & created plan of care 93 yo Lives in ALF PMH: diastolic CHF, HTN, tachyarrhythmia s/p pacemaker, Afib, COPD, CKD stage 3, diet controlled DM type II, right adhesive capsulitis s/p right rotator cuff injury, recurrent UTIs, functional urinary incontinence with chronic urinary leakage, fecal incontinence, moderate generalized DJD, gait ataxia, dysphagia, Parkinsonism, intrarenal hemorrhage, mild Alzheimer’s dementia Face to face visits: 2/4/15 chronic disease mgmt COPD exacerbation 2/11/15 active mgmt of COPD exacerbation

11. GG’s initial CCM Plan of Care Chronic Condition #1 CHF Chronic Condition# 2 HTN Current health care providers: MD, CNP Functional status: ambulatory w/ rollator w/ assist x2 w/ gait belt, moderate limitations Cognitive/mental health: alert & oriented x 3, mild Alzheimer’s dementia Expected outcome & prognosis: #1 symptom management to decrease exacerbations and promote quality of life and prevent hospitalizations. #2 stable BP with goal to avoid dizziness and decrease risk of falls. Prognosis: fair Patient’s goals of care: remain at ALF, no hospitalizations, at home death Advanced Directives on file: Yes Medication Mgmt: At each face to face visit and prn. Medication reconciliation after each transition of care. ALF nurses administer medications. Measurement of treatment goals: BP stable, labs monitored, avoidance of hospitalizations for CHF mgmt Symptom management plan: monitor renal fxn and electrolytes, MWF weights w/ ALF LPN to call if gains 2# between weights or 4# in 7 days, vitals, Rx mgmt, ALF nurses to report SOB/DOE and worsening LE edema to office/on call provider for prompt intervention Community/Social Support Service Ordered: on site at ALF, POA/dtr very involved How services of agencies/specialists will be coordinated: PCP team will coordinate w/ ALF Identify individuals responsible for each area above: PCP/CNP/CC/ALF staff

12. GG March 2015: UTI, called to on call provider – less than 20 min of non face to face time for month– did not bill CCM April 2015: med refills, med changes, labs May 2015: med refills, coordination of care w/ ALF nurses and new orders June 2015: med mgmt July 2015: on call abnormal lab results, med refills, UA C&S, Estrace stopped, cipro for UTI, yeast cystitis

13. GG Aug 2015: UA C&S, coordination of care w/ POA/dtr, incontinence dermatitis tx, med refills Sept 2015: on call fell & sent to ED, team conference, care plan updated Oct 2015: med refill, CXR, labs ordered due to weight gain, edema, pain meds ordered Nov 2015: new wound under abdominal pannus, witnessed fall w/ PT & skin tears, weight gain, coordination of care w/ urologist for cystitis, elevated renal indices due to diuresis on labs, calls to on call, DME paperwork

14. GG Dec 2015: no CCM billed, coordination of care w/ urologist, addition of acidophilus while on antibiotics, planning ALF move coordination with POA, ALF DON and administrator, home care, ambulette then change in plan of care Goals of Care in GG’s own words: Code Status: DNRCC Never wanted to be hospitalized again Wanted to die at home Christmas dinner at current ALF

15. GG Making It Happen: Patient-driven goals of care Medication management Labs on site Needs a Hoyer lift Continuity of care team Wound care Coordinate with receiving ALF, ambulette, & home care agency Anticipatory guidance

16. Lessons Learned Don’t leave money on the table Get started on consent now Solutions-oriented thinking Your existing EHR CCM Program Hire a CCM manager Start documenting time Reviewing labs Phone messages E-prescribing Coordinating care with POAs, HHC, consultants, hospitals, EDs, etc

17. References Chronic Care Management Services. Centers for Medicare and Medicaid Services (online). Available at: https://www.cms.gov/Outreachhttps://www.cms.gov/Outreach -and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/ChronicCareMan agement.pdf-and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/ChronicCareMan agement.pdf. Accessed February 16, 2016.

18. Discussion Go to: 2Shoesapp.com/AAHCM20162Shoesapp.com/AAHCM2016 1.Click on the session you are in 2.Ask and vote on questions